Transfusion Outcomes in Patients Undergoing Unifocalization and Repair of Tetralogy of Fallot With Major Aortopulmonary Collaterals

Abstract

Background: Surgical repair of tetralogy of Fallot and major aortopulmonary collaterals (TOF/MAPCAs) involves unifocalization of MAPCAs and reconstruction of the pulmonary arterial circulation. Surgical and cardiopulmonary bypass (CPB) times are long and suture lines are extensive. Maintaining patency of the newly anastomosed vessels while achieving hemostasis is important, and assessment of transfusion practices is critical to successful outcomes. Methods: Clinical, surgical, and transfusion data in patients with TOF/MAPCAs repaired at our institution (2013-2018) were reviewed. Types and volumes of blood products used in the perioperative period, in addition to the use of antifibrinolytics and/or procoagulants (factor VIII inhibitor bypassing activity [FEIBA]; anti-inhibitor coagulant complex), were assessed. Outcome measures included days on mechanical ventilation (DOMV), postoperative intensive care unit and hospital length of stay (LoS), and incidence of thrombosis. Results: Perioperative transfusion data from 279 patients were analyzed. Surgical (879 ± 175 minutes vs 684 ± 257 minutes) and CPB times (376 ± 124 minutes vs 234 ± 122 minutes) were longer in patients who received FEIBA than those who did not. Although the indexed volume of packed red blood cells (128.4 ± 82.2 mL/kg) and fresh frozen plasma (64.2 ± 41.1 mL/kg) was similar in patients who did and did not receive FEIBA, the amounts of cryoprecipitate (5.5 ± 5.2 mL/kg vs 5.8 ± 4.8 mL/kg) and platelets (19.5 ± 20.7 mL/kg vs 20.8 ± 13 mL/kg) transfused were more in those who did receive FEIBA. Conclusion: Perioperative transfusion is an important component in the overall surgical and anesthetic management of patients with TOF/MAPCAs. The intraoperative use of FEIBA was not associated with a decrease in the amount of blood products transfused, DOMV, or LoS or with an increase in thrombotic complications.

Activated Prothrombin Complex Concentrate in Pediatric Cardiac Patients, Our Early Experience

“…A total of 105 patients who received 10 to 15 U/kg of FEIBA were compared to 174 controls who did not receive FEIBA. 8 Again, no difference in postoperative transfusion between FEIBA and non-FEIBA groups was observed and no thrombotic complications were associated with FEIBA. 8 The study by Navaratnam et al shared a statistical approach similar to ours and had positive findings.…”

“…8 Again, no difference in postoperative transfusion between FEIBA and non-FEIBA groups was observed and no thrombotic complications were associated with FEIBA. 8 The study by Navaratnam et al shared a statistical approach similar to ours and had positive findings. 15 It was demonstrated that in 43 matched pairs of neonates who did and did not receive FEIBA after bypass volume of allogeneic transfusion indexed by weight was lower in patients who received FEIBA.…”

“…The maximum FEIBA dose (15 U/kg) was four folds lower than the dose recommended by the manufacturer for hemophiliac patients 10 and was described in the context of CPB surgery in children in the past. 8,11 If after FEIBA bleeding persisted, more blood products were administered at the discretion of the anesthesiologist. In control patients, hemostatic efforts were similar with the exception of FEIBA administration (Supplemental Table 1).…”

Primary causes of In-Hospital Mortality in Pediatric Cardiac Surgery Population

“…So in above mentioned CHDs of our population, pulmonary hypertension and and RV dysfunction with or without valve regurgitation are major primary cause that lead to in-hospital mor-tality. In CHDs like TOF, raise hematocrit and platelet dysfunction make hemostatic process challenging during course of surgery and early ICU stay 17 . At the same time complexity of disease and presence of RV dysfunction and valve regurgitation like TR or PR after surgery make overall patient management a big challenge.…”

Understanding and managing the complex balance between bleeding and thrombosis following cardiopulmonary bypass in paediatric cardiac surgical patients

“…Moreover, Wise-Faberowski et al examined their use of FEIBA at a 10-15 U/kg in a large series of children undergoing unifocalisation in Tetralogy of Fallot with major aortopulmonary collaterals at their institution. 38 They concluded that the intraoperative use of FEIBA was not associated with a decrease in the amount of blood products, days of mechanical ventilation, length of stay, or an increase in recognised thrombotic events compared to those patients who did not receive FEIBA.…”